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Health Information : Management of a Strategic Resource

ISBN: 9780721686479 | 0721686478
Format: Hardcover
Publisher: Saunders
Pub. Date: 12/11/2000

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SummaryTable of Contents
This book has been thoroughly revised and updated to reflect the vast technological changes in the field for 2-year or 4-year health management programs. This text focuses on health data, its collection and use. It emphasizes the deployment of information technology and the role of the HIM professional in the development of the electronic health record.
SECTION I Foundations of Health Information Management
Health Care Systems
3(46)
Midge Noel Ray
Evolution of... MORE
4(1)
Historical Development
5(5)
Early Forms of Health Care---2700 BC to the Eighteenth Century
5(1)
Health Care in the Nineteenth Century
6(1)
Twentieth-Century Reforms
7(1)
Complexity of Health Care Today
8(2)
Healthy People 2000
10(1)
Regulatory Agencies and Organizations
10(6)
Federal Government as Regulator
11(2)
Role of States
13(1)
Legislation
14(1)
Accreditation
15(1)
Regulatory Mechanisms of Health Occupations
16(1)
Health Care Delivery Systems
16(18)
Issues and Trends
16(1)
Continuum of Care
17(1)
Ambulatory Care
18(3)
Hospitals
21(10)
Home Care (Home Health Care)
31(1)
Long-Term Care Facilities
31(1)
Hospice Care
32(1)
Adult Day Care Services
33(1)
Subacute Care
33(1)
Mobile Diagnostic Services
33(1)
Contract Services
33(1)
Multihospital Systems
33(1)
Health Care Reform of the 1990s
34(1)
Health Care Professionals
34(5)
Health Care Team
34(5)
Health Care Team Models for Care
39(1)
Financing Health Care
39(5)
Reimbursement
39(2)
Government's Role as Payer
41(1)
Managed Care
42(2)
Utilization Review
44(1)
Technology in Health Information
44(2)
Point-of-Care Clinical Information Systems
44(1)
Electronic Data Interchange
45(1)
Other Information Technology
45(1)
Institute of Medicine
45(1)
Future Issues
46(3)
The Health Information Management Profession
49(24)
Shirley A. Eichenwald
Him---A Profession in Transformation
50(2)
The Profession Defined
50(1)
Him Roles in the Workplace
50(2)
The Patient Record---A Valuable Primary Source of Health Data and Information
52(1)
Forces Influential in the Evolution of Patient REcords
53(3)
From the Beginning to 1900
53(1)
From 1900 to Today
54(2)
The Evolving Patient Record System
56(1)
External Influences on the Him Profession
57(4)
Voluntary Standards and Regulations
58(1)
Medicare and Medicaid
58(1)
Tax Equity and Fiscal Responsibility Act
59(1)
Health Insurance Portability and Accountability Act
59(1)
Computer Technologies
59(1)
Malpractice Claims
60(1)
Health Care Reorganization
60(1)
Development of the Him Profession
61(3)
Formation of the Association
61(1)
Development of Formal Educational Programs
62(1)
Accreditation of Educational Programs
63(1)
Certification and Registration Programs
64(2)
RRL to RRA to RHIA
64(1)
CRL and FHIMA
64(1)
ART to RHIT
65(1)
Certified Coding Specialist Credentials---CCS and CCS-P
65(1)
Continuing Education Requirements
65(1)
The Ahima Today
66(2)
Structure
66(1)
Membership
67(1)
Mission
67(1)
The Professioal Code of Ethics
67(1)
Looking to the Future
68(5)
SECTION II Health Care Data
Data Collection Standards
73(72)
Mary Spivey Teslow
Donna J. Wilde
Health Data Users and Decision Making
74(2)
Users and Uses of Health Data
74(2)
Decision Making
76(1)
Overview of the Patient Record
76(1)
The Unique Roles of the Patient Health Record
76(1)
Definitions
77(1)
Data Collection Standards
77(12)
Nongovernmental
77(1)
Governmental
78(11)
Basic Principles of Data Collection
89(10)
User Needs
89(1)
General Forms and Views
89(9)
Format Types
98(1)
Methods to Ensure Data Quality
99(3)
Record Content Review and Retrospective Completion
99(3)
Data Quality Monitoring Methods and Solutions
102(5)
Quality Assessment and Improvement Study of Patient Record Documentation
102(1)
Special Concerns of Alternative Care Settings
103(1)
Clinical Staff Activities Related to Data Quality
104(1)
Facility Structure That Encourages Data Quality
105(1)
Characteristics of Data Quality
105(2)
Data Needs Across the Health Care Continuum
107(21)
Minimum Data Sets
107(1)
Ambulatory Care
108(5)
Acute Care
113(1)
Long-Term Care
114(5)
Rehabilitation
119(1)
Home Health Care
119(7)
Hospice
126(1)
Behavioral Health
127(1)
Computerized Patient Record Initiatives
128(4)
ASTM E1384 Content Guide for Computer-Based Patient Records
128(1)
ASTM E1384 Major Segments
129(3)
Summary and Management Issues
132(3)
Appendix A Sample Health Record Reports
135(8)
Appendix B Recommended Joint Commission Documentation Review Criteria
143(2)
Data Quality and Technology
145(32)
Donna J. Wilde
Mary Spivey Teslow
Database Structure and Model
146(6)
Data Model
146(1)
Characters, Fields, Records, and Files
146(1)
Types of Data
147(1)
Selection of Appropriate Type of Data Management Software
148(4)
Data Quality and Computer Systems
152(6)
Issues and Characteristics
152(2)
Design of Computer Systems to Ensure Data Quality
154(4)
Design and Control of Paper Forms and Computer Views
158(1)
Forms and Computer Views
158(8)
Forms or Views Team
159(1)
General Design Principles
159(6)
Other Display Features
165(1)
General Control Principles
166(1)
Forms/Views Summary
166(1)
Report Accuracy
166(1)
Testing Database Program Design
167(1)
Backup and Data Retention
167(1)
Data Security Procedures
168(1)
Documentation of Instruction to Support the Database
168(1)
Training
168(1)
Data Quality Monitoring Methods and Solutions
168(1)
Architecture
168(4)
Hardware
168(1)
Electronic Data Entry Technology
169(3)
Output
172(1)
Software
173(1)
Communications
174(1)
Local Area Networks
174(1)
Wide Area Networks
174(1)
Client-Server Technology
174(1)
Internet
174(1)
Summary
175(2)
Data Access and Retention
177(52)
Lynn Kuehn
Darice M. Grzybowski
Access and Retention of Paper-Based Records
178(22)
Record Identification
178(1)
Filing Equipment
179(3)
Space Management
182(1)
Filing Methodologies
182(3)
Master Patient Index
185(3)
Records Management Issues
188(6)
Record Tracking
194(4)
Record Retention
198(2)
Disaster Recovery for Paper-Based Records
200(1)
Computer Technology in Automated Data Access and Retention
200(5)
Hardware
201(1)
Input, Output, and Storage Devices
201(1)
Terminals and Workstations
201(1)
Pen-based Devices
202(1)
Document Imaging Devices
203(1)
Voice Recognition
203(1)
Communications
204(1)
Client Server Technology
205(1)
Access and Retention of Image-Based Records
205(24)
Micrographics
205(9)
Optical Image Processing
214(15)
Coding, Classification, and Reimbursement Systems
229(34)
Elizabeth D. Bowman
Importance of Coding
230(1)
Coding
230(1)
Purposes of Coding
230(1)
Nomenclatures
230(1)
Classification Systems
231(1)
Coding Systems in Use
231(3)
International Classification of Diseases
231(1)
HCFA Common Procedural Coding System
232(2)
Coding Systems and Reimbursement
234(1)
Inpatient Coding Process
234(2)
Diagnosis Related Groups
236(5)
Effect of the DRG Reimbursement System on the Inpatient Coding Process
240(1)
Coding Outpatient or Ambulatory Care Records
241(4)
Ambulatory Care Reimbursement Systems
243(2)
Impact of Computers on the Coding and Reimbursement Process
245(1)
Ethical Problems in Coding
245(3)
Quality of Coded Data
248(2)
Elements of Quality Coding
250(1)
Causes of Errors in Coding
250(1)
Failure to Review Entire Record
250(1)
Selection of Incorrect Principal Diagnosis
250(1)
Selection of Incorrect Code
251(1)
Coding Diagnoses or Procedures Not Validated by Record Content
251(1)
Clerical Errors in Database or on Bill
251(1)
Improving the Quality of Coding
251(1)
Developing Coding Policies
251(1)
Quality Improvement Studies
251(1)
Documentation Guidelines
252(1)
Measuring Coding Productivity (Quality and Quantity)
252(1)
Considerations in Hiring Coders
252(2)
Determining the Number of Coders Needed
254(1)
Training Coders
254(1)
Retention of Coders
255(1)
Coding Resources
255(1)
Use of Contract Coding and Drg Review Services
256(1)
Other Coding and Classification Systems
256(2)
Diagnostic and Statistical Manual of Mental Disorders
257(1)
International Classification of Diseases for Oncology
257(1)
Systematized Nomenclature of Human and Veterinary Medicine International
257(1)
Read Codes
257(1)
LOINC Codes
257(1)
Case Mix and Severity of Illness Systems
257(1)
Future of Coding
258(5)
SECTION III Data Management and Use
Registries
263(44)
Sue Watkins
History and Development of Cancer Registries
264(2)
Hospital Cancer Registries
264(1)
Population-Based Registries
264(2)
Hospital Cancer Registry Model
266(20)
Database Development and Management
266(8)
Patient Follow-Up
274(4)
Space, Equipment, and Supplies
278(2)
Automation
280(1)
Confidentiality and Release of Information
281(1)
Policies and Procedures
281(2)
Use of Cancer Registry Data
283(2)
Staffing
285(1)
Approved Cancer Program
286(2)
Cancer Committee
286(1)
Cancer Conferences (Tumor Boards)
287(1)
Documentation
287(1)
National Cancer Registrars Association, Inc.
288(1)
AIDS Registries
288(4)
Database Management
288(3)
Automation
291(1)
Uses of AIDS Registy Data
291(1)
Birth Defects Registries
292(1)
Database Management
292(1)
Diabetes Registries
293(5)
Database Management
295(2)
Automation
297(1)
Follow-Up
297(1)
Use of Diabetes Registry Data
297(1)
Implant Registries
298(2)
Organ Transplant Registries
300(1)
Database Management
300(1)
Quality Assurance
300(1)
Training
301(1)
Trauma Registries
301(6)
Database Management
301(1)
Automation
302(1)
Quality Control
303(4)
Statistics
307(33)
Valerie J. M. Watzlaf
Elaine Rubinstein
Overview of Statistics and Data Presentation
308(1)
Role of the Him Professional
308(1)
Health Care Statistics
308(14)
Vital Statistics
308(1)
Rates, Ratios, Proportions, and Percentages
309(1)
Mortality Rates
310(6)
Autopsy Rates
316(1)
Morbidity Rates
317(2)
Census Statistics
319(3)
Organizing and Displaying the Data
322(4)
Types of Data
322(1)
Types of Data Display
323(3)
Statistical Measures and Tests
326(3)
Measures of Central Tendency
326(2)
Measures of Dispersion
328(1)
Inferential Statistics
329(11)
Tests of Significance
329(7)
Interval Estimation
336(1)
Sampling and Sample Size
337(3)
Research and Epidemiology
340(33)
Valerie J. M. Watzlaf
Overview of Research and Epidemiology
342(1)
Role of the Him Professional
342(1)
Designing the Research Proposal
343(6)
Hypothesis and Research Questions
343(1)
Review of Literature
344(1)
Methodology (Draft)
345(1)
Research Plan
345(4)
Validity and Reliability
349(3)
Validity
349(1)
Sensitivity and Specificity
349(1)
Reliability
350(2)
Biases
352(1)
Confounding Variables
352(1)
Sampling Variability
352(1)
Ascertainment or Selection Bias
352(1)
Diagnosis Bias
352(1)
Nonresponse Bias
352(1)
Survival Bias
352(1)
Recall Bias
352(1)
Interviewer Bias
353(1)
Prevarication Bias
353(1)
Epidemiologic Study Designs
353(11)
Descriptive Study
353(8)
Experimental Epidemiology
361(3)
Use of Computers in Research
364(2)
Outcome Studies and Epidemiology
366(7)
Study Procedures
366(1)
Data Analysis
367(6)
Quality Management and Clinical Outcomes
373(53)
Donna J. Slovensky
Purpose and Philosophy of Management in Health Care
374(7)
Historical Development
375(1)
Medical Education Reform
375(1)
Role of the Joint Commission on Accreditation of Healthcare Organizations
376(1)
Provider Accountability and Outcomes Reporting
377(1)
National Committee for Quality Assurance
378(1)
Federal Legislation
378(2)
Quality Awards
380(1)
Clinical Quality Improvement
381(9)
Historical Development
381(1)
Objectives
381(1)
External Requirements
381(1)
Internal Incentives
381(1)
Clinical Reviews
382(1)
Other Reviews
382(2)
Methodology and Models
384(6)
Quality Improvement
390(10)
Theoretic and Conceptual Foundations
390(1)
Quality Management Gurus
391(2)
Quality Improvement Methods and Models
393(1)
Quality Improvement Tools
394(5)
Clinical and Administrative Use of QI Information
399(1)
Utilization Management
400(7)
Historical Development
400(1)
Objectives
401(1)
External Requirements
402(1)
Internal Incentives
402(1)
Program Components
402(4)
Methodology
406(1)
Clinical and Administrative Use of UM Information
407(1)
Risk Management
407(5)
Historical Development
407(1)
Objectives
407(1)
External Requirements
408(1)
Internal Incentives
408(1)
Program Components
408(2)
Methodology
410(1)
Clinical and Administrative Use of Risk Management Information
411(1)
Credentialing
412(9)
Historical Development
412(1)
Objectives
413(1)
External Requirements
413(2)
Internal Incentives
415(1)
Program Components
415(2)
Methodology
417(4)
Clinical and Administrative Use of Credentialing Information
421(1)
Medical/Professional Staff Organization
421(5)
Bylaws, Rules, and Regulations
421(1)
MSO Structure
421(1)
Executive Committee
422(1)
Committee Reporting Structure
422(1)
Clinical and Administrative Use of Committee Information
422(4)
Health Law Concepts and Practices
426(49)
Jill Callahan Dennis
Why Are Legal Issues Important to Health Information Management Professionals?
428(1)
Fundamentals of the Legal System
428(2)
Sources of Law
428(2)
The Legal System
430(6)
The Court System
430(2)
Cases That Involve Health Care Facilities and Providers
432(4)
Legal Obligations and Risks of Health Care Facilities and Individual Health Care Providers
436(39)
Duties to Patients, in General
436(1)
Duty to Maintain Health Information
437(1)
Duty to Retain Health Information and Other Key Documents and to Keep Them Secure
438(4)
Duty to Maintain Confidentiality
442(3)
Internal and External Users of Health Information
445(1)
General Principles Regarding Access and Disclosure Policies
445(16)
Duty to Provide Care That Meets Professional Standards
461(1)
Duty to Obtain Informed Consent to Treatment
462(2)
Duty to Provide a Safe Environment for Patients and Visitors
464(1)
Duty to Supervise the Actions of Employees and the Professional Staff
465(4)
Contract Liability Issues and the HIM Department
469(1)
Legal Resources for HIM Professionals
470(5)
SECTION IV Management
Principles of Management
475(5042)
W. Jhack Suncan
Peer M. Ginter
Management: Defining the Field
476(3)
Management as a Process
476(1)
A Brief History of Management
477(2)
Understanding Strategic Management
479(3)
Situational Analysis
479(2)
Strategy Formulation
481(1)
Strategic Implementation
481(1)
Strategic Control
481(1)
Nature of Managerial Work
482(2)
Overview of Research
482(1)
Analysis of Managerial Functions
483(1)
Five Functions of Management
484(22)
Planning and Goal Setting
485(3)
Principles of Effective Planning
488(1)
Organizing for Action
488(6)
Another View of Organizing
494(1)
Principles of Effective Organizing
495(1)
Making Management Decisions
496(2)
Essential Principles of Decision Making
498(1)
Leading and Managing
499(2)
Principles of Leading
501(1)
Controlling: Completing the Management Loop
502(3)
Principles of Management Control
505(1)
Understanding Job Descriptions
506(5011)
Evolution of Job Description
506(1)
Relating Organizational Goals to Job Descriptions
506(5011)
Operational Management
5517
Carol Enable
Anita Hazelwood
Individual Work Processes (Micro Level)
518(18)
Organizing Work
518(1)
Work Distribution Chart
518(5)
Productivity
523(3)
Work Simplification or Methods Improvement
526(10)
Systems and Organizational Level (Midlevel)
536(5)
Systems Analysis and Design
536(4)
Organizational Structure
540(1)
Organization-Wide Level
541(9)
Project Management
541(7)
Reengineering
548(2)
Design and Management of Space in Health Information Services
550(12)
Work Space Design
550(4)
Design of the Workstation
554(8)
Human Resource Management
562(58)
Wesley M. Rohrer III
Human Resource Management
564(54)
Navigating Through Turbulent Times
564(1)
Broad Environmental Forces
564(1)
Forces Transforming Health Care
564(1)
Challenges for Health Information Management Professionals
565(1)
Systems Perspective
565(1)
Environmental Influences and Human Resource Management
566(4)
Inputs (Human Resources)
570(1)
Legal and Regulatory Requirements Affecting Human Resource Management
571(9)
Internal Environment
580(4)
Systems Approach Applied to Health Information Services
584(1)
Systems Perspective Applied to Health Resource Management
584(34)
Future Issues
618(2)
Financial Management
620(34)
Mary Alice Hanken
Historical Perspective
622(2)
Payment for Health Care Services
622(2)
Setting Priorities for Financial Decisions
624(1)
Mission
624(1)
Goals
624(1)
Objectives
625(1)
The Business Plan and Budget
625(3)
Identifying Trends
626(1)
Staffing Information
626(1)
Program and Automation Assessments
626(1)
The Four M's
626(1)
Developing the Bushiness Plan and Budget
627(1)
Budgets
628(3)
Statics Budget
628(1)
Operating Budget
629(1)
Master Budget
629(1)
Who Participates in Budget Development?
629(1)
Budget Periods and Types
629(1)
Budgeting for Staff
630(1)
Using the Budget as a Control
630(1)
Participating in the Management of Revenue
631(4)
Charge Master
631(2)
Claims Analysis
633(1)
Case Mix Analysis
634(1)
Revenue Versus Cash
634(1)
The HIM Professional's Role in the Cash Budget
634(1)
Patient Accounting
635(1)
Financial Aspects of Fraud and Abuse Compliance
635(1)
Cost Allocations
636(2)
Why Does Allocation Occur?
636(1)
Allocation Methods
637(1)
Why Is Cost Allocation Methodology Important for the HIM Professional?
638(1)
Health Care Accounting and Fiance
638(2)
Cash and Accrual Systems
638(2)
Fiscal Periods
640(1)
Using Financial Reports to Provide Management Information
640(1)
Using Ratios to Evaluate Financial Data
640(4)
Liquidity Ratio
643(1)
Turnover Ratio or Activity Ratio
643(1)
Performance Ratio
644(1)
Capitalization Ratio
644(1)
Capital Expense and Investment Decisions
644(6)
Capital Expenditures
645(1)
Capital Request Evaluation Process
645(1)
Time Value of Mone
645(1)
Compounding
645(1)
Discounting
646(1)
Net Present Value
647(2)
Accounting Rate of Return
649(1)
Payback Method
649(1)
Arguments Pro and Con for Evaluation Methods
650(1)
Other Phases of Financial Management
650(4)
Implementing
650(1)
Seeking Alternatives
650(1)
Role of the HIM Profession in Financial Management
650(4)
SECTION V Information Systems
Technology, Applications, and Security
654(34)
Melissa Saul
Health Information Infrastructure, Technology, and Applications
656(12)
Scope of Health Information Systems
656(1)
Computers in Health Care---Past and Present
657(3)
Computer Fundamentals
660(1)
Software
661(7)
Computer Applications
668(4)
Administrative Applications
668(1)
Clinical Applications
669(3)
Emerging Technologies
672(4)
Inernet
672(4)
Telemedicine
676(1)
Fundamentals
676(1)
Implementation
676(1)
Telemed---An Example
677(1)
Computer Security
677(5)
Authentication Tools
678(2)
Reporting Capabilities
680(1)
Physical Security
680(1)
External Controls
680(2)
Data Management Technology
682(6)
Data Mart
682(3)
Data Modeling
685(3)
Electronic Health Records: A Unifying Principle
688(32)
Gretchen F. Murphy
Electronic Health Records, Past and Present
691(1)
The Present Goal: Computer-Bsed Patient Records (CPRs) to the Electronic Health Record (EHR)
692(7)
Electronic Health Records to Meet Challenges of Increased Demands
692(1)
Drawbacks of Using Paper Records
693(1)
Defining a New Model
694(1)
More Sophisticated Functionality Through a New Model
694(2)
EHR Building Blocks: Data and Technology Infrastructure
696(1)
Vocabularies, Codes, and Text Processing
697(2)
Strategic Recommendations
699(1)
Progress Toward an Electronic Health Record
699(3)
The Electronic Health Record: Is It Still a Dream?
699(1)
Orders Communication: Better Management of Care and Data
700(1)
Brigham and Women's Hospital and Partners Healthcare System
701(1)
New Ideas in Development
701(1)
Health Information systems and EHRs: Selected Issues and Barriers
702(4)
Costs
703(1)
Technology Infrastructure and Customer Expectations
703(1)
Legislation
703(1)
Confidentiality and Security
704(1)
Health Care Information Processing Standards
705(1)
American National Standards Institute
706(1)
Managing the Transition: Challenge to Health Information Professions
706(14)
EHR Working Assumptions: Planning for 2010
712(1)
Sleeting an Approach to EHR Development
712(8)
Information Systems Life Cycle
720(53)
Merida L. Johns
Introduction
722(1)
System Analysis, Design, and Implementation
722(1)
Role of the HIM Professional
723(1)
System Life Cycles
723(5)
General System Life Cycle
724(1)
Information System Life Cycle
724(1)
Information System Life Cycles in the Organization
724(2)
Aggregate Information Life Cycle of the Organization
726(1)
System Obsolescence
727(1)
Information System Development Life Cycle
728(1)
Analysis
729(22)
Tools and Aids for System Analysis
729(11)
Investigate Strategies for Analysis of Requirements
740(6)
Analysis Document
746(1)
System Design
747(1)
Design Principles
748(3)
Role of Prototyping in System Development
751(1)
System Implementation
752(4)
User Preparation and Training
752(1)
Site Preparation
753(1)
System Testing and Conversion
754(1)
Startup
754(2)
System Evaluation and Benefits Realization
756(5)
Benefits Realization
757(1)
Cost-Benefit Analysis
757(2)
Cost-Effectiveness Analysis
759(1)
Other Evaluation Methods and Techniques
760(1)
Purchasing Process: Request for Proposal
761(12)
Planning Steps Before RFP Preparation
762(1)
Analyzing System Requirements
762(1)
Development of System Specifications
762(1)
Development and Distribution of the RFP
763(4)
Evaluation Criteria
767(2)
Demonstrations and Site Visits
769(1)
System Selecting and Contract Negotiation
770(3)
Glossary773(39)
Index812

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